Breast and cervical cancer in 187 countries between 1980 and 2010: a systematic analysis

Computer vision-based breast self-examination stroke position and palpation pressure level classification using artificial neural networks and wavelet transforms

This paper focuses on breast self-examination (BSE) stroke position and palpation level classification for the development of a computer vision-based BSE training and guidance system. In this study, image frames are extracted from a BSE video and processed considering the color information, shape, and texture by wavelet transform and first order color moment. The new approach using artificial neural network and wavelet transform can identify BSE stroke positions and palpation levels, i.e. light, medium, and deep, at 97.8 % and 87.5 % accuracy respectively.

Objective assessment of cosmetic outcome after targeted intraoperative radiotherapy in breast cancer: results from a randomised controlled trial

The international randomised targeted intraoperative radiotherapy (TARGIT) trial has demonstrated evidence of non-inferiority between the novel technique of TARGIT (intra-operative radiotherapy with Intrabeam(®)) and conventional external beam radiotherapy (EBRT) in women with early breast cancer in terms of the primary outcome measure of risk of local relapse within the treated breast. Cosmesis is an increasingly important outcome of breast conserving treatment with both surgery and radiotherapy contributing to this. It was unknown if the single high dose of TARGIT may lead to damaging fibrosis and thus impair cosmesis further, so we objectively evaluated the aesthetic outcome of patients within the TARGIT randomised controlled trial. We have used an objective assessment tool for evaluation of cosmetic outcome. Frontal digital photographs were taken at baseline (before TARGIT or EBRT) and yearly thereafter for up to 5 years. The photographs were analysed by BCCT.core, a validated software which produces a composite score based on symmetry, colour and scar. 342 patients were assessed, median age at baseline 64 years (IQR 59-68). The scores were dichotomised into Excellent and Good (EG), and Fair and Poor (FP). There were statistically significant increases in the odds of having an outcome of EG for patients in the TARGIT group relative to the EBRT group at year 1 (OR 2.07, 95 % CI 1.12-3.85, p = 0.021) and year 2 (OR 2.11, 95 % CI 1.0-4.45, p = 0.05). Following a totally objective assessment in a randomised setting, the aesthetic outcome of patients demonstrates that those treated with TARGIT have a superior cosmetic result to those patients who received conventional external beam radiotherapy.

Are prognostic factors more favorable for breast cancer detected by organized screening than by opportunistic screening or clinical diagnosis? A study in Loire-Atlantique (France)

PURPOSE

Comparisons of breast cancer characteristics between organized and opportunistic screening have been limited. This study was designed to compare characteristics of cancers detected by either organized or opportunistic screening as well as clinically diagnosed cancers in Loire-Atlantique (a French administrative entity), from 2003 to 2007.

METHODS

This study is based on data from the population-based Loire-Atlantique Cancer Registry. Stage at diagnosis and prognostic characteristics of carcinomas detected by organized screening were compared, by age-adjusted logistic regressions, to those of cancers detected by opportunistic screening and diagnosed clinically. Analyses were restricted to women aged 50-74 years (the age group targeted by the organized screening program) for the 2003-2007 period.

RESULTS

Between 2003 and 2007, 2864 invasive and 400 in situ breast cancer cases were diagnosed in women aged 50-74 years in Loire-Atlantique. Compared to cancers diagnosed clinically, cancers detected by organized screening were more likely to be in situ (13.7% vs. 3.8%), diagnosed at an early stage (74.4% vs. 51.3%), have a low SBR grade (grade 1: 35.4% vs. 18.5%), and be positive for estrogen-progesterone receptors (68.3% vs. 59.0%). The distribution of stage at diagnosis and prognostic characteristics between organized and opportunistic screening were similar.

CONCLUSION

These findings are consistent with the hypothesis that breast cancers are detected early by organized screening. Cancer characteristics were similar between the two screening modes. Estimating the impact of mammography screening on mortality in Loire-Atlantique should be the object of further investigations.

MYC overexpression and poor prognosis in sporadic breast cancer with BRCA1 deficiency

Breast cancer is a complex disease; the molecular mechanisms involved in sporadic breast carcinogenesis remain to be elucidated. The present study aimed to explore the deficiency of breast cancer susceptibility gene 1 (BRCA1), including protein loss expression, promoter hypermethylation and gene copy deletion, its correlationship with other tumor markers expression (TP53, MYC, etc.), and clinical significance in sporadic breast cancer. BRCA1 protein expression was negative in 226 of 374 (60.4%) cases of this study. Cases negative for BRCA1 protein were more often with pathological tumor-node-metastasis stage III, positive for lymph node metastasis and MYC overexpression than BRCA1-positive tumors. BRCA1 hypermethylation was detected in 16.4% (31 of 189) breast cancers, which correlated with BRCA1 negative, ER negative, MYC overexpression, and triple-negative phenotype. In addition, the percentage of cells with BRCA1 gene copy deletion was significantly increased in BRCA1-methylated tumors. Kaplan-Meier survival analysis showed that patients with BRCA1-negative expression showed a worse overall survival (OS) than those with BRCA1-positive expression, and patients with BRCA1-methylated tumors had a significantly worse disease-free survival than did patients with unmethylated tumors. Furthermore, BRCA1 hypermethylation showed an inverse association with OS in LN-positive or p53-negative subgroup patients. Importantly, uni- and multivariate Cox regression analyses revealed that BRCA1 was an independent prognostic indicator of OS in sporadic breast cancer. Thus, we found MYC overexpression and poor prognosis in sporadic breast cancer with BRCA1 deficiency. The targeting of BRCA1 deficiency in combination with MYC-pathways inhibitors may provide a promising strategy for sporadic breast cancer care, the triple-negative subtype in particular.

Activation of SNAT1/SLC38A1 in human breast cancer: correlation with p-Akt overexpression

BACKGROUND

SNAT1 is a subtype of the amino acid transport system A that has been implicated to play a potential role in cancer development and progression, yet its role in breast cancer remains unclear. In present study, we detected SNAT1 expression in breast cancers and explored its underlying mechanism in promoting breast carcinogenesis.

METHODS

RT-PCR and Western blotting were performed to analyze the transcription and protein levels of SNAT1 in breast cancer cell lines and fresh tissues. Tissue microarray blocks containing breast cancer specimens obtained from 210 patients were constructed. Expression of SNAT1 in these specimens was analyzed using immunohistochemical studies. SNAT1 was down-regulated by SNAT1-shRNA in breast cancer cells and the functional significance was measured.

RESULTS

SNAT1 was up-regulated in breast cancer cell lines and breast cancer tissues. Overexpression of SNAT1 was observed in 127 cases (60.5%). Expression of SNAT1 was significantly associated with tumor size, nodal metastasis, advanced disease stage, Ki-67, and ER status. Suppression of endogenous SNAT1 leads to cell growth inhibition, cell cycle arrest, and apoptosis of 4T1 cells and lowered the phosphorylation level of Akt. SNAT1 expression correlated significantly with p-Akt expression in human breast cancer samples.

CONCLUSIONS

The cross-talk between Akt signaling and SNAT1 might play a critical role in the development and progression of breast cancer, providing an important molecular basis for novel diagnostic markers and new attractive targets in the treatment of breast cancer patients.

FOXM1 promotes the epithelial to mesenchymal transition by stimulating the transcription of Slug in human breast cancer

The Forkhead Box M1 (FOXM1) transcription factor is involved in tumorigenesis and tumor progression in multiple human carcinomas. In this study, we found that FOXM1 promoted the epithelial to mesenchymal transition (EMT) in human breast cancer. We observed a strong correlation between the expression levels of FOXM1 and the mesenchymal phenotype. Knockdown of FOXM1 inhibited the mesenchymal phenotype, whereas stable overexpression of FOXM1 induced EMT in breast cancer cells. FOXM1 was found to endogenously bind to and stimulate the promoter of Slug that is crucial for EMT progression. The knockdown of Slug abolished the EMT-inducing function of FOXM1. The stable overexpression of FOXM1 promoted metastasis of breast cancer cells in vivo. This study confirmed that FOXM1 promoted EMT in breast cancer cells by stimulating the transcription of EMT-related genes such as Slug.

Glycoprotein non-metastatic b (GPNMB): A metastatic mediator and emerging therapeutic target in cancer

Molecularly targeted therapies are rapidly growing with respect to their clinical development and impact on cancer treatment due to their highly selective anti-tumor action. However, many aggressive cancers such as triple-negative breast cancer (TNBC) currently lack well-defined therapeutic targets against which such agents can be developed. The identification of tumor-associated antigens and the generation of antibody drug-conjugates represent an emerging area of intense interest and growth in the field of cancer therapeutics. Glycoprotein non-metastatic b (GPNMB) has recently been identified as a gene that is over-expressed in numerous cancers, including TNBC, and often correlates with the metastatic phenotype. In breast cancer, GPNMB expression in the tumor epithelium is associated with a reduction in disease-free and overall survival. Based on these findings, glembatumumab vedotin (CDX-011), an antibody-drug conjugate that selectively targets GPNMB, is currently being investigated in clinical trials for patients with metastatic breast cancer and unresectable melanoma. This review discusses the physiological and potential pathological roles of GPNMB in normal and cancer tissues, respectively, and details the clinical advances and challenges in targeting GPNMB-expressing malignancies.

Prevalence and type distribution of high-risk human papillomavirus in patients with cervical cancer: a population-based study

Background

Cervical cancer is the greater cause of cancer death in women in many developing countries. Persistent infection with human papilloma virus (HPV), primarily high risk types 16 and 18, is recognized as a causal and essential factor for the development of cervical cancer. We aimed to determine the distribution of high-risk HPV genotypes in archival biopsies with cervical carcinoma in patients from Mazandaran Province, Northern Iran.

Methods

A total of 98 paraffin-embedded cervical samples consisted of 63 Squamous Cell Carcinomas (SCC), 4 Adenocarcinomas, 19 Cervical Interaepithelial Neoplasia grade I (CIN-I), 4 CIN-II and 8 CIN-III diagnosed during 2009–2011, were selected to perform high risk HPV genotyping using AmpliSens^(R) HPV HCR DNA genotyping kit. The prevalence of HPV infections was assessed in low and high grade cervical lesions by age.

Results

Of the 98 cervical samples analysed by DNA PCR, 78 (79.59%) were positive for HPV DNA. HPV was detected in the 52 of SCC, 4 of Adenocarcinomas, 14 of CIN-I, 4 of CIN-II, and 4 of CIN-III for HPV. From the 78 HPV positive samples, 23 (29.5%) samples were positive for HPV type 16, 32 (41%) were positive for HPV 18, 19 (24.4%) were positive for HPV 45, and 4 (5.1%) of cervical specimens were positive for HPV 39.

Conclusions

This study provides valuable baseline data for future assessment of the impact of current prophylactic vaccination programs that is protective against the two most common oncogenic types of HPV found in cervical cancer, HPV-16 and HPV-18, but not against other high-risk mucosal HPVs, 39 and 45, reported in this population.

Integrative analysis of cancer-related signaling pathways

Identification and classification of cancer types and subtypes is a major issue in current cancer research. Whole genome expression profiling of cancer tissues is often the basis for such subtype classifications of tumors and different signatures for individual cancer types have been described. However, the search for best performing discriminatory gene-expression signatures covering more than one cancer type remains a relevant topic in cancer research as such a signature would help understanding the common changes in signaling networks in these disease types. In this work, we explore the idea of a top down approach for sample stratification based on a module-based network of cancer relevant signaling pathways. For assembly of this network, we consider several of the most established cancer pathways. We evaluate our sample stratification approach using expression data of human breast and ovarian cancer signatures. We show that our approach performs equally well to previously reported methods besides providing the advantage to classify different cancer types. Furthermore, it allows to identify common changes in network module activity of those cancer samples.

Predictors of breast cancer screening uptake: a pre intervention community survey in Malaysia

INTRODUCTION

Despite health education efforts to educate women on breast cancer and breast cancer screening modalities, the incidence of breast cancer and presentation at an advanced stage are still a problem in Malaysia.

OBJECTIVES

To determine factors associated with the uptake of breast cancer screening among women in the general population.

METHODS

This pre-intervention survey was conducted in a suburban district. All households were approached and women aged 20 to 60 years old were interviewed with pre-tested guided questionnaires. Variables collected included socio-demographic characteristics, knowledge on breast cancer and screening practice of breast cancer. Univariate and multivariate analysis were performed.

RESULTS

41.5% of a total of 381 respondents scored above average; the mean knowledge score on causes and risks factors of breast cancer was 3.41 out of 5 (SD1.609). 58.5% had ever practiced BSE with 32.5% performing it at regular monthly intervals. Uptake of CBE by nurses and by doctors was 40.7% and 37.3%, respectively. Mammogram uptake was 14.6%. Significant predictors of BSE were good knowledge of breast cancer (OR=2.654, 95% CI: 1.033-6.816), being married (OR=2.213, 95% CI: 1.201-4.076) and attending CBE (OR=1.729, 95% CI: 1.122-2.665). Significant predictors for CBE included being married (OR=2.161, 95% CI: 1.174-3.979), good knowledge of breast cancer (OR=2.286, 95% CI: 1.012-5.161), and social support for breast cancer screening (OR=2.312, 95% CI: 1.245-4.293). Women who had CBE were more likely to undergo mammographic screening of the breast (OR=5.744, 95% CI: 2.112-15.623), p<0.005.

CONCLUSION

CBE attendance is a strong factor in promoting BSE and mammography, educating women on the importance of breast cancer screening and on how to conduct BSE. The currently opportunistic conduct of CBE should be extended to active calling of women for CBE.

High-risk human papillomavirus among HIV-infected women with normal cervical cytology: a pilot study in Jos, Nigeria

BACKGROUND

Cervical cancer is strongly linked to high-risk human papillomavirus (HR-HPV) and is typically preceded by cytological abnormalities. Less is known in patients with normal cervical cytology (NCC). We investigated the epidemiology of HR-HPV among HIV-infected women with NCC.

METHODOLOGY

We conducted a cross-sectional study between January and June 2011 among HIV-infected women with NCC at an adult HIV clinic in Jos, Nigeria. Cervical sampling and analysis for HR-HPV by hybrid capture (HC2) with signal amplification was done to determine presence of one or more of the following HR-HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 or 68. Epidemiologic factors associated with HR-HPV were determined using bivariate statistics and multivariate logistic regression.

RESULTS

We evaluated 103 HIV-infected women with Pap cytology. The median age of the women was 32 years (range 21-49). Ninety-seven (94.2%) had NCC. Cervical samples for HR-HPV DNA testing were available from 89/97 (91.8%) of the HIV-infected women with NCC. Of the 89 women with cervical samples for HR-HPV DNA testing, 40 (44.9%) had detectable HR-HPV by HC2 giving a HR-HPV prevalence of 44.9% (95% CI 33.9-55.5%). Age < 30 years was associated with HR-HPV (OR 2.69 [95% CI 1.05-6.91, p = 0.039]) while history of previous abortion showed an inverse association with HR-HPV (OR 0.33[95% CI 0.15-0.94, p = 0.039]).

CONCLUSION

The prevalence of HR-HPV is seemingly high among HIV-infected women with NCC in our clinical setting. These data provide support for further investigation of the clinical implications of positive HR-HPV among HIV-infected women with NCC report in cervical cancer prevention programs in Nigeria.

Human papillomavirus detection: testing methodologies and their clinical utility in cervical cancer screening

Human papillomavirus (HPV) is a well-studied etiologic agent for cervical cancer dysplasia and neoplasia. HPV E6 and E7 viral proteins drive oncogenesis by blocking the activity of pRB and p53, respectively. Consensus screening guidelines focus on appropriate use of both cervical cytology and HPV testing to reduce the morbidity and mortality associated with cervical cancer. HPV testing is indicated for women aged 21 to 64 years with atypical squamous cells of undetermined significance (ASC-US) on cytology. In women aged 30 to 64, testing is also indicated for routine screening in conjunction with cervical cytology. Various methods are available for HPV detection and several Food and Drug Administration-approved assays are on the market using either signal or target amplification methodologies. Most of the approved tests target DNA, but tests for mRNA detection are also available. Recently, assays for type specific detection of HPV types 16 and 18 have been Food and Drug Administration approved, and the use of genotyping has been incorporated into management algorithms. HPV testing can be performed on liquid-based cytology samples and options for automation are available making the introduction of HPV testing into many pathology laboratories possible.

Estimating the five-year survival of cervical cancer patients treated in hospital universiti sains malaysia

OBJECTIVE

The objective of this study was to determine the five-year survival among patients with cervical cancer treated in Hospital Universiti Sains Malaysia.

METHODS

One hundred and twenty cervical cancer patients diagnosed between 1st July 1995 and 30th June 2007 were identified. Data were obtained from medical records. The survival probability was determined using the Kaplan-Meier method and the log-rank test was applied to compare the survival distribution between groups.

RESULTS

The overall five-year survival was 39.7% [95%CI (Confidence Interval): 30.7, 51.3] with a median survival time of 40.8 (95%CI: 34.0, 62.0) months. The log-rank test showed that there were survival differences between the groups for the following variables: stage at diagnosis (p=0.005); and primary treatment (p=0.0242). Patients who were diagnosed at the latest stage (III-IV) were found to have the lowest survival, 18.4% (95%CI: 6.75, 50.1), compared to stage I and II where the five-year survival was 54.7% (95%CI: 38.7, 77.2) and 40.8% (95%CI: 27.7, 60.3), respectively. The five-year survival was higher in patients who received surgery [52.6% (95%CI: 37.5, 73.6)] as a primary treatment compared to the non-surgical group [33.3% (95%CI: 22.9, 48.4)].

CONCLUSION

The five-year survival of cervical cancer patients in this study was low. The survival of those diagnosed at an advanced stage was low compared to early stages. In addition, those who underwent surgery had higher survival than those who had no surgery for primary treatment.

Upregulation of microRNA-224 is associated with aggressive progression and poor prognosis in human cervical cancer

Objective

Accumulating evidence for differential expression of microRNA-224 (miR-224) in various types of human cancer suggests that it may be play a crucial role in tumor biology. The previous microarray detection also shown that miR-224 was one of miRNAs with significant upregulation in cervical cancer tissues relative to adjacent normal tissues. However, little is known about the function of miR-224 in human cervical cancer. The aim of this study was to investigate the clinical significance of miR-224 expression in cervical cancer.

Methods

MiR-224 expression in 126 pairs of fresh human cervical cancer and adjacent normal tissues was measured by real-time quantitative RT-PCR assay.

Results

miR-224 expression was significantly upregulated in cervical cancer tissues when compared with corresponding adjacent normal tissues (P < 0.001). It was also significantly higher in the cancerous tissues of patients with advanced FIGO stage cervical cancer than those with early FIGO stage (P = 0.02). In addition, miR-224 was expressed at significantly higher levels in lymph node metastasis-positive patients than in lymph node metastasis-negative patients (P = 0.008). Moreover, we found that lesser differentiated tumors expressed higher miR-224 (P = 0.03). Finally, there were sufficient evidence to confirm its value in the status of vascular invasion (P = 0.01) and human papillomavirus (HPV) infection (P = 0.02) in cervical cancer. More importantly, Kaplan-Meier analysis showed that cervical cancer patients with high miR-224 expression tend to have shorter overall survival. In multivariate analysis stratified for known prognostic variables, miR-224 was identified as an independent prognostic marker.

Conclusion

Our data indicated that miR-224 upregulation was associated with aggressive progression and poor prognosis in cervical cancer. MiR-224 was identified for the first time as an independent marker for predicting the clinical outcome of cervical cancer patients.

Virtual slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/2170449349527493

Defective antioxidant systems in cervical cancer

Cervical cancer remains a great problem for woman health, as it is the second deadly cancer of females worldwide. The infection of human papilloma virus (HPV) is the major risk factor for this cancer, although several other factors are also associated. Oxidative stress or antioxidant deficiency has been frequently identified to be associated with cervical cancer. Defects in the antioxidant enzyme systems are reported to play important role behind this antioxidant deficiency, which is responsible for the production of reactive oxygen species and ultimately, DNA damage in cervical cells. In response, cells become more vulnerable to HPV infection for cervical cancer development. Recently, antioxidant therapies or dietary supplementation of antioxidants have gained considerable interests in the cervical cancer treatment. In this study, we have reviewed the association of defective antioxidant systems and cervical cancer development. The recent advances in both of the basic and clinical research focusing on possible antioxidant therapy have also been discussed.

Comparing thirty-day outcomes in prosthetic and autologous breast reconstruction: a multivariate analysis of 13,082 patients?

BACKGROUND

There is a paucity of multi-institutional data that directly compares short term outcomes of autologous and prosthetic breast reconstruction. The National Surgical Quality Improvement Program provides a unique data platform for evaluating peri-operative outcomes of these two main categories of breast reconstruction. It has detailed data from nearly 250 hospitals and over 13,000 patients. We performed risk-adjusted analysis of prosthetic and autologous breast reconstruction to compare 30-day morbidity outcomes.

METHODS

Patients who underwent prosthetic breast reconstruction or autologous tissue reconstruction from 2006 to 2010 were identified using operation descriptions. Over 240 tracked variables were extracted for patients undergoing breast reconstruction. Thirty-day postoperative outcomes were compared, and subgroup analysis was performed on the autologous population to describe outcomes of specific flap procedures. Reconstruction was analyzed as an independent risk factor for specific complications, with propensity scores used to help standardize compared patient populations. Regression analyses were performed using SPSS (version 20.0, Chicago, IL).

RESULTS

A total of 13,082 patients underwent breast reconstruction; 9786 patients received prosthetic reconstruction and 3296 received autologous reconstruction. Within the autologous cohort, 1608 (48.8%) patients underwent a pedicle TRAM flap, 1079 (32.7%) had a LD flap, and 609 (18.5%) received a free flap. Autologous reconstruction patients had higher rates of overall complications (12.47% vs 5.38%, p<.001), wound infection (5.46% vs 3.45%, p<.001), prosthesis/flap failure (3.13% vs 0.85%, p<.001), and reoperation (9.59% vs 6.76%, p<.001). Risk-adjusted multivariate analysis also showed autologous reconstruction to be a significant independent predictor of specific short term outcomes.

CONCLUSIONS

Using risk-adjusted models of a large multi-institutional database, we found that--relative to prosthetic reconstruction--autologous reconstruction had higher rates of 30-day overall complications, wound infection, prosthesis/flap failure, and reoperation. This may be due, in part, to a concomitant increase in operative time and higher case complexity. Taken with other reports such as NMBRA, this study helps to educate patients and surgeons alike on potential, comparative complications during the perioperative period.

A systemic assessment of the association between tumor necrosis factor alpha 308 G/A polymorphism and risk of cervical cancer

Tumor necrosis factor alpha (TNF-α) is a multifunctional cytokine which plays an important role in the human immune response against various pathogens, and there may be a relationship between TNF-α 308 G/A polymorphism and cervical cancer risk. We performed a meta-analysis to get a systemic assessment of the association between TNF-α 308 G/A polymorphism and cervical cancer risk. Electronic searches of PubMed, Embase, and Web of Science were performed for all publications on the association between TNF-α 308 G/A polymorphism and cervical cancer risk through October 26, 2012. The pooled odds ratios (ORs) with their 95 % confidence interval (95 % CIs) were calculated to assess the association. Fifteen studies with a total of 3,743 cervical cancer cases and 4,096 controls were finally included into the meta-analysis. Overall, TNF-α 308 G/A polymorphism was significantly associated with increased risk of cervical cancer under three main genetic comparison models (A vs. G, OR 1.20, 95 % CI 1.02-1.42, P=0.03; AA vs. GG, OR 1.31, 95 % CI 1.00-1.72, P=0.048; AA vs. GG/GA, OR 1.30, 95 % CI 1.00-1.71, P=0.05). Subgroup analysis by ethnicity further showed that there was a significant association between TNF-α 308 G/A polymorphism and increased risk of cervical cancer in Asians (AA vs. GG, OR 1.83, 95 % CI 1.05-3.20, P=0.034; AA vs. GG/GA, OR 1.84, 95 % CI 1.05-3.22, P=0.032). The meta-analysis suggests that TNF-α 308 G/A polymorphism is associated with increased risk of cervical cancer, and TNF-α 308 G/A mutant allele A is a risk factor of cervical cancer.

Polymorphisms in oxidative stress-related genes and mortality in breast cancer patients--potential differential effects by radiotherapy?

We assessed whether variants in 22 oxidative stress-related genes are associated with mortality of breast cancer patients and whether the associations differ according to radiotherapy. Using a prospective cohort of 1348 postmenopausal breast cancer patients, we estimated hazard ratios (HR) and 95% confidence intervals (CI) for 109 single nucleotide polymorphisms (SNPs) using Cox proportional hazards regression. Validation of results was attempted using two Scandinavian studies. Eleven SNPs in MT2A, NFE2L2, NQO1, PRDX1, and PRDX6 were significantly associated with overall mortality after a median follow-up of 5.7 years. Three SNPs in NQO1 (rs2917667) and in PRDX6 (rs7314, rs4916362) were consistently associated with increased risk of dying across all three study populations (pooled: HRNQO1_rs2917667 1.20, 95% CI 1.00-1.44, p = 0.051; HRPRDX6_rs7314 1.16, 95% CI 1.00-1.35, p = 0.056, HRPRDX6_rs4916362 1.14 95% CI 1.00-1.32, p = 0.062). Potential effect modification by radiotherapy was found for CAT_rs769218. In conclusion, genetic variants in NQO1 and PRDX6 may modify breast cancer prognosis.

Trends in the incidence of cancer in the black population of Harare, Zimbabwe 1991-2010

Incidence rates of different cancers have been calculated for the black population of Harare, Zimbabwe for a 20-year period (1991-2010) coinciding with continuing social and lifestyle changes, and the peak, and subsequent wane, of the HIV-AIDS epidemic. The overall risk of cancer increased during the period in both sexes, with rates of cervix and prostate cancers showing particularly dramatic increases (3.3% and 6.4% annually, respectively). By 2004, prostate cancer had become the most common cancer of men. The incidence of cancer of the esophagus, formerly the most common cancer of men, has remained relatively constant, whereas rates of breast and cervix cancers, the most common malignancies of women, have shown significant increases (4.9% and 3.3% annually, respectively). The incidence of Kaposi sarcoma increased to a maximum around 1998-2000 and then declined in all age groups, and in both sexes The incidence of squamous cell cancers of the conjunctiva is relatively high, with temporal trends similar to those of Kaposi sarcoma. Non-Hodgkin lymphoma, the fifth most common cancer of men and fourth of women, showed a steady increase in incidence throughout the period (6.7-6.9% annually), although rates in young adults (15-39) have decreased since 2001. Cancer control in Zimbabwe, as elsewhere in sub-Saharan Africa, involves meeting the challenge of emerging cancers associated with westernization of lifestyles (large bowel, breast and prostate), while the incidence of cancers associated with poverty and infection (liver, cervix and esophagus) shows little decline, and the residual burden of the AIDS-associated cancers remains significant.

Radical Surgery With Individualized Postoperative Radiation for Stage IB Cervical Cancer: Oncologic Outcomes and Severe Complications

Objective

The objective of this study was to compare morbidity and outcome following radical surgery with or without adjuvant radiation therapy (RT) in the treatment of stages IB1-IB2 cervical carcinoma.

Methods

We retrospectively identified 222 patients with stages IB1-IB2 cervical carcinoma treated initially with radical hysterectomy or radical trachelectomy with or without adjuvant RT from February 2000 to November 2009. All grade 3 or higher complications—those requiring interventional radiology, endoscopic evaluation, or operative intervention—were documented.

Results

One hundred fifty-eight patients (71%) underwent radical hysterectomy; 64 (29%) underwent radical trachelectomy. One hundred fifty-three patients (69%) underwent surgery alone; 69 (31%) received adjuvant radiation with or without chemosensitization. There was a statistically significant difference in the rate of total grades 1 to 5 late complications between the surgery-alone and surgery + RT groups (12% vs 32%, respectively; P < 0.001); however, the rate of grade 3 or higher complications was similar (5% vs 4%, respectively; P = 0.999). The progression-free and overall survival rates of the entire cohort were both 95%. The 5-year progression-free survival rates for the surgery-alone and surgery + RT groups were 93% and 90% (P = 0.172). The overall survival rates were 96% and 91%, respectively (P = 0.332).

Conclusions

The majority of women with stages IB1-IB2 cervical cancer undergoing radical surgery do not require adjuvant RT, have excellent oncologic outcome, and have low severe complication rates. Nearly one third of our patients required postoperative radiation, with no statistically significant increase in severe complication rate and with similar oncologic outcomes compared with the surgery-only cohort. These data support the continued practice of radical surgery with individualized postoperative radiation for these patients.

Household income is associated with the p53 mutation frequency in human breast tumors

BACKGROUND

A study from Scotland reported that the p53 mutation frequency in breast tumors is associated with socio-economic deprivation.

METHODS

We analyzed the association of the tumor p53 mutational status with tumor characteristics, education, and self-reported annual household income (HI) among 173 breast cancer patients from the greater Baltimore area, United States.

RESULTS

p53 mutational frequency was significantly associated with HI. Patients with < $15,000 HI had the highest p53 mutation frequency (21%), followed by the income group between $15,000 and $60,000 (18%), while those above $60,000 HI had the fewest mutations (5%). When dichotomized at $60,000, 26 out of 135 patients in the low income category had acquired a p53 mutation, while only 2 out of 38 with a high income carried a mutation (P < 0.05). In the adjusted logistic regression analysis with 3 income categories (trend test), the association between HI and p53 mutational status was independent of tumor characteristics, age, race/ethnicity, tobacco smoking and body mass. Further analyses revealed that HI may impact the p53 mutational frequency preferentially in patients who develop an estrogen receptor (ER)-negative disease. Within this group, 42% of the low income patients (< $15,000 HI) carried a mutation, followed by the middle income group (21%), while those above $60,000 HI did not carry mutations (Ptrend < 0.05).

CONCLUSIONS

HI is associated with the p53 mutational frequency in patients who develop an ER-negative disease. Furthermore, high income patients may acquire fewer p53 mutations than other patients, suggesting that lifetime exposures associated with socio-economic status may impact breast cancer biology.

Influencing women's actions on cervical cancer screening and treatment in Karawang District, Indonesia

INTRODUCTION

The impact of cervical cancer prevention programs depends on persuading women to go for screening and, if needed, treatment. As part of an evaluation of a pilot project in Indonesia, qualitative research was conducted to explore the factors that influence women's decisions regarding screening and treatment and to generate practical recommendations to increase service coverage and reduce loss to follow up.

METHODS

Research was conducted at 7 of the 17 public health centers in Karawang District that implemented the pilot project. Interviews and focus group discussions were held with 20 women, 20 husbands, 10 doctors, 18 midwives, 3 district health officials, and 16 advocacy team members.

RESULTS

Free services and mobile outreach events encouraged women to go for screening, along with promotional efforts by community health workers, advocacy teams, and the mass media. Knowledge and perceptions were the most important barriers to screening: women were not aware of cervical cancer risks, did not know the disease was treatable, and were fatalistic. Factors facilitating treatment were social support from husbands, relatives, and friends and the encouragement and role modeling of health workers. Barriers to prompt treatment included limited access to services and the requirement for husband's consent for cryotherapy.

CONCLUSION

As cervical cancer prevention services are scaled up throughout Indonesia, the findings suggest three strategies to expand screening coverage and ensure prompt treatment: strengthening community mobilization and advocacy activities, modifying the service delivery model to encourage a single visit approach to screening and treatment, and working to gain men's support.

Passive smoking and cervical cancer risk: a meta-analysis based on 3,230 cases and 2,982 controls

OBJECTIVE

Passive smoking has been considered as a risk factor of many cancers. To examine whether it might also pose a risk for cervical cancer, we performed a meta-analysis based on published case-control studies.

METHODS

We searched the PubMed database and references of included studies up to February 10th, 2012 for relevant studies. After two authors independently assessed the methodological quality and extracted data, a meta-analysis was conducted using CMA v2 software. Publication bias was evaluated by funnel plot, using Egger's and Begg's tests.

RESULTS

Finally 11 eligible studies yielded, involving 3,230 cases and 2,982 controls. The results showed that women who never smoke but exposed to smoking experience a 73% increase in risk of cervical cancer compared with non-exposed women (OR = 1.73, 95% CI = 1.35 - 2.21, p<0.001). Subgroup and sensitivity analyses indicated this result to be robust. Moderate publication bias was detected by visualing funnel plot, Egger's and Begg's tests.

CONCLUSION

Based on currently available evidence, the findings of this meta-analysis suggests that passive smoking significantly and independently increases the risk of cervical cancer.

Lactate dehydrogenase-B is silenced by promoter methylation in a high frequency of human breast cancers

OBJECTIVE

Under normoxia, non-malignant cells rely on oxidative phosphorylation for their ATP production, whereas cancer cells rely on Glycolysis; a phenomenon known as the Warburg effect. We aimed to elucidate the mechanisms contributing to the Warburg effect in human breast cancer.

EXPERIMENTAL DESIGN

Lactate Dehydrogenase (LDH) isoenzymes were profiled using zymography. LDH-B subunit expression was assessed by reverse transcription PCR in cells, and by Immunohistochemistry in breast tissues. LDH-B promoter methylation was assessed by sequencing bisulfite modified DNA.

RESULTS

Absent or decreased expression of LDH isoenzymes 1-4, were seen in T-47D and MCF7 cells. Absence of LDH-B mRNA was seen in T-47D cells, and its expression was restored following treatment with the demethylating agent 5'Azacytadine. LDH-B promoter methylation was identified in T-47D and MCF7 cells, and in 25/25 cases of breast cancer tissues, but not in 5/5 cases of normal breast tissues. Absent immuno-expression of LDH-B protein (<10% cells stained), was seen in 23/26 (88%) breast cancer cases, and in 4/8 cases of adjacent ductal carcinoma in situ lesions. Exposure of breast cancer cells to hypoxia (1% O(2)), for 48 hours resulted in significant increases in lactate levels in both MCF7 (14.0 fold, p = 0.002), and T-47D cells (2.9 fold, p = 0.009), but not in MDA-MB-436 (-0.9 fold, p = 0.229), or MCF10AT (1.2 fold, p = 0.09) cells.

CONCLUSIONS

Loss of LDH-B expression is an early and frequent event in human breast cancer occurring due to promoter methylation, and is likely to contribute to an enhanced glycolysis of cancer cells under hypoxia.

Induction of apoptosis in human breast cancer cells via caspase pathway by vernodalin isolated from Centratherum anthelminticum (L.) seeds

BACKGROUND

Centratherum anthelminticum (L.) seeds (CA) is a well known medicinal herb in Indian sub-continent. We recently reported anti-oxidant property of chloroform fraction of Centratherum anthelminticum (L.) seeds (CACF) by inhibiting tumor necrosis factor-α (TNF-α)-induced growth of human breast cancer cells. However, the active compounds in CACF have not been investigated previously.

METHODOLOGY/PRINCIPAL FINDINGS

In this study, we showed that CACF inhibited growth of MCF-7 human breast cancer cells. CACF induced apoptosis in MCF-7 cells as marked by cell size shrinkage, deformed cytoskeletal structure and DNA fragmentation. To identify the cytotoxic compound, CACF was subjected to bioassay-guided fractionation which yielded 6 fractions. CACF fraction A and B (CACF-A, -B) demonstrated highest activity among all the fractions. Further HPLC isolation, NMR and LC-MS analysis of CACF-A led to identification of vernodalin as the cytotoxic agent in CACF-A, and -B. 12,13-dihydroxyoleic acid, another major compound in CACF-C fraction was isolated for the first time from Centratherum anthelminticum (L.) seeds but showed no cytotoxic effect against MCF-7 cells. Vernodalin inhibited cell growth of human breast cancer cells MCF-7 and MDA-MB-231 by induction of cell cycle arrest and apoptosis. Increased of reactive oxygen species (ROS) production, coupled with downregulation of anti-apoptotic molecules (Bcl-2, Bcl-xL) led to reduction of mitochondrial membrane potential (MMP) and release of cytochrome c in both human breast cancer cells treated with vernodalin. Release of cytochrome c from mitochondria to cytosol triggered activation of caspase cascade, PARP cleavage, DNA damage and eventually cell death.

CONCLUSIONS/SIGNIFICANCE

To the best of our knowledge, this is the first comprehensive study on cytotoxic and apoptotic mechanism of vernodalin isolated from the Centratherum anthelminticum (L.) seeds in human breast cancer cells. Overall, our data suggest a potential therapeutic value of vernodalin to be further developed as new anti-cancer drug.

Breast cancer screening: review of benefits and harms, and recommendations for developing and low-income countries

Breast cancer is the most common cancer in women worldwide. The disease remains a public health concern as recent evidence indicates that the breast cancer burden has increased mainly in developing and low-income countries (DLICs). Despite the demonstrated benefits, the debate about the real benefits and harms of breast cancer screening is ongoing. Many experts believe that the benefits of screening, in terms of reduced breast cancer mortality, outweigh the harms, whereas others think the opposite. In this review, we assess the clinical utility of available screening modalities, present evidence, overdiagnosis, cost-effectiveness, and other pertinent issues. We also examine relevant data from DLICs to underscore the barriers and challenges that impede implementation of screening strategies in those populations. We also provide recommendations concerning rational preventive strategies for breast cancer control for women in DLICs.

MYBBP1A suppresses breast cancer tumorigenesis by enhancing the p53 dependent anoikis

Background

Tumor suppressor p53 is mutated in a wide variety of human cancers and plays a critical role in anoikis, which is essential for preventing tumorigenesis. Recently, we found that a nucleolar protein, Myb-binding protein 1a (MYBBP1A), was involved in p53 activation. However, the function of MYBBP1A in cancer prevention has not been elucidated.

Methods

Relationships between MYBBP1A expression levels and breast cancer progression were examined using patient microarray databases and tissue microarrays. Colony formation, xenograft, and anoikis assays were conducted using cells in which MYBBP1A was either knocked down or overexpressed. p53 activation and interactions between p53 and MYBBP1A were assessed by immunoprecipitation and western blot.

Results

MYBBP1A expression was negatively correlated with breast cancer tumorigenesis. In vivo and in vitro experiments using the breast cancer cell lines MCF-7 and ZR-75-1, which expresses wild type p53, showed that tumorigenesis, colony formation, and anoikis resistance were significantly enhanced by MYBBP1A knockdown. We also found that MYBBP1A binds to p53 and enhances p53 target gene transcription under anoikis conditions.

Conclusions

These results suggest that MYBBP1A is required for p53 activation during anoikis; therefore, it is involved in suppressing colony formation and the tumorigenesis of breast cancer cells. Collectively, our results suggest that MYBBP1A plays a role in tumor prevention in the context of p53 activation.

Temporal trends in the relative survival among women with cervical cancer in Canada: a population-based study

OBJECTIVE

Cervical cancer was estimated to affect approximately 1300 women in Canada in 2011, and 350 women were expected to die from this disease. We estimated the trends in the relative survival ratio for patients diagnosed with epithelial invasive cervical cancer in Canadian population during the period 1992-2005.

METHODS

A flexible parametric model was used to estimate the relative survival ratio. Relative survival ratio is defined as the observed survival among patients with cancer divided by the expected survival in the general population. We incorporated age group, histology of tumor, geographical region, and year of diagnosis in the model to predict 2- and 5-year relative survival ratios.

RESULTS

A total of 13,424 patients with a diagnosis of epithelial invasive cervical cancer were included in this analysis, whose mean (SD) age was 49.3 (16.0) years at the time of diagnosis. The histologic classification of the cervical tumor was squamous for 75.4% of the cases followed by glandular for 18.5% of the cases. Other epithelial tumors accounted for 6.2% of the cases. The same pattern was observed for all regions. The glandular and the "other epithelial" cancers had the best and worst survival, respectively. Fifty percent of all cases were diagnosed in Ontario.

CONCLUSIONS

This article indicates gradual improvements for relative survival ratio for all age groups, all types of tumor, and all geographical regions in Canada during the 1992-2005 period. The improvements may be related to evolutions in screening, diagnosis, and treatment. Further progress may be achieved by extending the screening coverage, possibly changing the screening test, or advances in treatment.

A lectin with highly potent inhibitory activity toward breast cancer cells from edible tubers of Dioscorea opposita cv. nagaimo

A 70-kDa galactose-specific lectin was purified from the tubers of Dioscorea opposita cv. nagaimo. The purification involved three chromatographic steps: anion exchange chromatography on a Q-Sepharose column, FPLC-anion exchange chromatography on a Mono Q column, and FPLC-gel filtration on a Superdex 75 column. The purified nagaimo lectin presented as a single 35-kDa band in reducing SDS-PAGE while it exhibited a 70-kDa single band in non-reducing SDS-PAGE suggesting its dimeric nature. Nagaimo lectin displayed moderate thermostability, retaining full hemagglutinating activity after heating up to 62°C for 30 minutes. It also manifested stability over a wide pH range from pH 2 to 13. Nagaimo lectin was a galactose-specific lectin, as evidenced by binding with galactose and galactose-containing sugars such as lactose and raffinose. The minimum concentration of galactose, lactose and raffinose required to exert an inhibitory effect on hemagglutinating activity of nagaimo lectin was 20 mM, 5 mM and 40 mM, respectively. Nagaimo lectin inhibited the growth of some cancer cell lines including breast cancer MCF7 cells, hepatoma HepG2 cells and nasopharyngeal carcinoma CNE2 cells, with IC(50) values of 3.71 µM, 7.12 µM and 19.79 µM, respectively, after 24 hour treatment with nagaimo lectin. The induction of phosphatidylserine externalization and mitochondrial depolarization indicated that nagaimo lectin evoked apoptosis in MCF7 cells. However, the anti-proliferative activity of nagaimo lectin was not blocked by application of galactose, signifying that the activity was not related to the carbohydrate binding specificity of the lectin.

Inhibition of FOXM1 transcription factor suppresses cell proliferation and tumor growth of breast cancer

The forkhead box M1 (FOXM1) transcription factor regulates the expression of genes essential for cell proliferation and transformation and is implicated in tumorigenesis and tumor progression. FOXM1 has been considered as a potential target for the prevention and/or therapeutic intervention in human carcinomas. In this study, we observed a strong expression of FOXM1 in clinical tissue specimens and cell lines of human breast cancer and a correlation between FOXM1 levels and the proliferation ability in the tested MCF-7, MDA-MB-231 and ZR-75-30 cells. By using an adenovirus vector (named AdFOXM1shRNA) that expresses a short hairpin RNA (shRNA) to downregulate FOXM1 expression specifically, we found that the knockdown of FOXM1 expression diminished the proliferation and anchorage-independent growth of the breast cancer cells. The FOXM1 silencing in ZR-75-30 cells dramatically prevented the tumorigenicity of the AdFOXM1shRNA-treated cells in vitro and in vivo. Furthermore, the efficacy of AdFOXM1shRNA for tumor gene therapy was assessed with the breast cancer xenograft mouse model and the tumor growth was significantly suppressed when inoculated mice were injected with AdFOXM1shRNA in the tumors. Together, our results suggest that FOXM1 is a potential therapeutic target for breast cancer and AdFOXM1shRNA may be an additional gene therapeutic intervention for breast cancer treatment.

Engaging in health behaviors to lower risk for breast cancer recurrence

PURPOSE

While post-treatment breast cancer survivors face up to twice the cancer risk of the general population, modifiable health behaviors may somewhat reduce this risk. We sought to better understand health behaviors that early stage breast cancer survivors engage in to reduce recurrence risk.

METHODS

Data came from a cross-sectional multi-site survey of 186 early-stage breast cancer survivors who received genomic testing for breast cancer recurrence risk (Oncotype DX) during their clinical care. Study outcomes were meeting health behavior recommendations (daily fruit and vegetable intake, regular physical activity, and having a healthy body mass index (BMI)).

RESULTS

Approximately three-quarters of survivors we surveyed believed the 3 behaviors might reduce their cancer risk but many did not engage in these behaviors for this purpose: 62% for BMI, 36% for fruit and vegetable consumption, and 37% for physical activity. Survivors with higher recurrence risk, as indicated by their genomic test results, were no more likely to meet any of the three health behavior recommendations. Adherence to health behavior recommendations was higher for women who were white, college-educated, and had higher incomes.

CONCLUSIONS

Many nonadherent breast cancer survivors wish to use these behavioral strategies to reduce their risk for recurrence, suggesting an important opportunity for intervention. Improving BMI, which has the largest association with cancer risk, is an especially promising target.

Correlation of immunoglobulin G expression and histological subtype and stage in breast cancer

INTRODUCTION

Recently, growing evidence indicates that immunoglobulins (Igs) are not only produced by mature B lymphocytes or plasma cells, but also by various normal cells types at immune privileged sites and neoplasm, including breast cancer. However, the association of breast cancer derived IgG with genesis and development of the disease has not yet been established.

METHODS

In this study we examined the expression of IgG in 186 breast cancers, 20 benign breast lesions and 30 normal breast tissues. Both immunohistochemistry with antibodies to Igκ (immunoglobulin G κ light chain) and Igγ (immunoglobulin G heavy chain) and in situ hybridization with an antisense probe to IgG1 heavy chain constant region gene were performed. Various clinicopathological features were also analyzed.

RESULTS

We found that IgG is specifically expressed in human breast cancer cells. Both infiltrating ductal carcinoma and infiltrating lobular carcinoma had significantly greater numbers of Igκ and Igγ positive cancer cells as compared with medullary carcinoma, carcinoma in situ, and benign lesions (all p<0.05). In addition, IgG expression was correlated with breast cancer histological subtypes (p<0.01) and AJCC stages (p<0.05), with more abundance of IgG expression in more malignant histological subtypes or in more advanced stage of the disease.

CONCLUSIONS

IgG expression in breast cancer cells is correlated with malignancy and AJCC stages of the cancers. This suggests that breast cancer derived IgG may be associated with genesis, development and prognosis of the cancer.

Current recommendations for cervical cancer screening: do they render the annual pelvic examination obsolete?

The development of a screening test for cervical dysplasia has been a major force in diminishing the worldwide incidence of invasive cervical cancer. Screening intervals recommended by professional organizations have changed over the past half century. Recognition of the human papillomavirus (HPV) as the causative agent and enhanced understanding of the natural history of HPV and cervical dysplasia in different age groups have prompted the American College of Obstetricians and Gynecologists and other professional societies to defer Pap smear screening to intervals no less than 2 years apart in women 21-29, and every 3 years in women 30 and over assuming no prior history of cervical dysplasia. Screening should start no sooner than age 21. These recommendations more closely resemble those currently practiced in Europe and other parts of the developed world. Those who have undergone hysterectomy no longer need screening unless high-grade dysplasia was present. Although the value of pelvic examination is not debated in women with symptoms referable to the female genital tract, the endorsement by several professional societies of less than annual cervical cancer screening in healthy women also begs the question of whether annual pelvic examination (speculum and/or bimanual examination) benefits asymptomatic women. Some sexually transmitted infections are amenable to self-insertion of a vaginal probe or detectable by voided urine specimen. Bimanual examination is insensitive in detecting early ovarian cancer with a high false-positive rate leading to patient anxiety, excessive diagnostic testing, and unnecessary surgical procedures. Future study should focus on the frequency in which healthy asymptomatic women should undergo pelvic examination.

History, biology, and health inequities: emergent embodied phenotypes and the illustrative case of the breast cancer estrogen receptor

How we think about biology--in historical, ecological, and societal context--matters for framing causes of and solutions to health inequities. Drawing on new insights from ecological evolutionary developmental biology and ecosocial theory, I question dominant gene-centric and ultimately static approaches to conceptualizing biology, using the example of the breast cancer estrogen receptor (ER). Analyzed in terms of its 4 histories--societal, individual (life course), tumor (cellular pathology), and evolutionary--the ER is revealed as a flexible characteristic of cells, tumors, individuals, and populations, with magnitudes of health inequities tellingly changing over time. This example suggests our science will likely be better served by conceptualizing disease and its biomarkers, along with changing magnitudes of health inequities, as embodied history--that is, emergent embodied phenotype, not innate biology.

Changing patterns in the clinical characteristics of korean breast cancer from 1996-2010 using an online nationwide breast cancer database

Purpose

Breast cancer is one of the most frequent malignancies in Korean women, and its incidence is increasing at a rapid rate. Since 1996, the Korean Breast Cancer Society has collected nationwide breast cancer data using an online registration program and analyzed the data biennial. The purpose of this study was to evaluate the characteristics of Korean breast cancer and to analyze changes in these characteristics over the period of time.

Methods

Data were collected from 41 medical schools (74 hospitals), 24 general hospitals, and 6 private clinics. Data on the total number, gender, and age of newly-diagnosed breast cancer patients were collected through a questionnaire. Additional data were collected and analyzed from the online database.

Results

In 2010, 16,398 patients in Korea were newly diagnosed with breast cancer. The crude incidence rate of female breast cancer was 67.2 cases per 100,000, and the median age at diagnosis was 49 years. The incidence of breast cancer was highest in patients aged between 40 and 49 years. Since 1996, there has been a significant increase in the proportion of early-stage cancers (detected in stage 1 or 2), the percentage of estrogen receptor-positive cancers, and in the proportion of patients receiving breast-conserving surgery.

Conclusion

The incidence and clinical characteristics of Korean breast cancer are slowly changing to the patterns of Western countries. To understand changing patterns in the characteristics of Korean breast cancer, the nationwide data should be continuously analyzed.

Gastric cancer incidence estimation in a resource-limited nation: use of endoscopy registry methodology

PURPOSE

Cancer epidemiology is challenging in developing nations, in the absence of reliable pathology-based cancer registries. Clinical experience suggests that the incidence of gastric cancer is high in Honduras, in contrast to the limited available national statistics at the time of study initiation (IARC GLOBOCAN 2002: males 15.2, females 10.8). We estimate the incidence of gastric cancer for Honduras using an endoscopy registry as a complimentary resource.

METHODS

We conducted a retrospective analysis of incident noncardia gastric adenocarcinoma cases in western Honduras for the period 2000-2009. This region is well circumscribed geopolitically with a single district hospital and established referral patterns, to provide a unique epidemiological niche to facilitate estimation of incidence rates. A prospective, comprehensive database of all endoscopy procedures from this hospital was utilized at the primary data source. The catchment area for gastroenterology services for the at-risk population was validated by calculating the overall endoscopy utilization rates for each municipality in western Honduras. Incident cases of gastric adenocarcinoma were determined by the endoscopic diagnosis. Pathology services are not financed by the Ministry of Health, and histology data were incorporated when available. Population statistics were obtained from the Honduras National Statistics Institute (INE). Age-standardized incidence rates (ASIRs) were calculated using world standard population fractions.

RESULTS

The catchment area for western Honduras was validated with the municipality threshold of 30 endoscopies per 10(6) person-years, with inclusion of a total of 40 municipalities. In the western Honduras catchment area, there were 670 incident cases (439 M, 231 F) of noncardia gastric adenocarcinoma during the study decade 2000-2009. Notably, 67 (10.0 %) and 165 (24.6 %) of cases were under the ages of 45 and 55, respectively. The case-finding rate was 5.1 endoscopies performed for each new diagnosis of gastric cancer. The ASIRs for the decade were 30.8 for males and 13.9 for females. Clinically, 60.3 % of gastric cancers were Borrmann type 3 (ulcerated mass), and evidence of advanced disease with pyloric obstruction was common (35.2 %). Subtypes by the Lauren classification were distributed among diffuse (56 %), intestinal (34 %), and indeterminate (9.9 %), in subjects with available pathology (526/670).

CONCLUSIONS

The endoscopy procedure registry may serve as a complimentary data resource for gastric cancer incidence estimation in resource-limited nation settings wherein pathology services and cancer registries are absent. The results remain an underestimation in this setting due to the challenges of access to care and related factors. The methodology helps to more fully characterize the high incidence of gastric cancer in western Honduras and this region of Central America and demonstrate the need for additional epidemiology research, and interventions focused on prevention and treatment.

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs).

METHODS

Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis.

FINDINGS

Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350,000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient -0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa.

INTERPRETATION

Rates of YLDs per 100,000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.

FUNDING

Bill & Melinda Gates Foundation.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010

BACKGROUND

Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

METHODS

We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

FINDINGS

In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45-54% since 1990; ischaemic heart disease and stroke YLLs increased by 17-28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer's disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

INTERPRETATION

Population growth, increased average age of the world's population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

FUNDING

Bill & Melinda Gates Foundation.

Differences in outcomes between elderly and nonelderly breast cancer patients in Louisiana

INTRODUCTION

Elderly breast cancer patients are diagnosed with a higher stage of disease. They are also found to undergo less surgery, receive more frequently hormonal treatment and have decreased relative survival. The interest of this study was to examine the differences in treatment and survival between elderly versus young (>65 versus <65) patients in Louisiana.

METHODS

The SEER database was searched, and all cases of female breast cancer in the state of Louisiana between 2000 and 2008 were analyzed. Data were stratified by age group and year of occurrence. The SEER definitions for breast cancer, surgery, chemotherapy, elderly populations, young populations, radiation therapy and breast conservative surgery were applied.

RESULTS

The state prevalence of localized breast cancer is lower compared with the national rate (128.5 versus 144, P < 0.001). The rate of regional breast disease is much higher in Louisiana patients than national average rate (69.7 versus 57.9, P < 0.001). There is no difference in disseminated disease. The elderly group was offered less surgery compared with the young group (11.39% versus 6.68%, P < 0.005). The elderly group received more general radiation interventions than the young group (65.97% versus 53.86%, P < 0.005). Mortality rates for the elderly group were higher in Louisiana compared with the national average. This difference was more remarkable in the >85 age group (127.8 versus 118.5, P < 0.001).

CONCLUSIONS

Differences between young and elderly breast cancer patients were observed. Mortality is higher among elderly breast cancer patients in Louisiana compared with the national average. Further studies are needed to review these differences.

Prevention of nodal metastases in breast cancer following the lymphatic migration of paclitaxel-loaded expansile nanoparticles

Although breast cancer patients with localized disease exhibit an excellent long-term prognosis, up to 40% of patients treated with local resection alone may harbor occult nodal metastatic disease leading to increased locoregional recurrence and decreased survival. Given the potential for targeted drug delivery to result in more efficacious locoregional control with less morbidity, the current study assessed the ability of drug-loaded polymeric expansile nanoparticles (eNP) to migrate from the site of tumor to regional lymph nodes, locally deliver a chemotherapeutic payload, and prevent primary tumor growth as well as lymph node metastases. Expansile nanoparticles entered tumor cells and paclitaxel-loaded eNP (Pax-eNP) exhibited dose-dependent cytotoxicity in vitro and significantly decreased tumor doubling time in vivo against human triple negative breast cancer in both microscopic and established murine breast cancer models. Furthermore, migration of Pax-eNP to axillary lymph nodes resulted in higher intranodal paclitaxel concentrations and a significantly lower incidence of lymph node metastases. These findings demonstrate that lymphatic migration of drug-loaded eNP provides regionally targeted delivery of chemotherapy to both decrease local tumor growth and strategically prevent the development of nodal metastases within the regional tumor-draining lymph node basin.

Who and what is a "population"? Historical debates, current controversies, and implications for understanding "population health" and rectifying health inequities

CONTEXT

The idea of "population" is core to the population sciences but is rarely defined except in statistical terms. Yet who and what defines and makes a population has everything to do with whether population means are meaningful or meaningless, with profound implications for work on population health and health inequities.

METHODS

In this article, I review the current conventional definitions of, and historical debates over, the meaning(s) of "population," trace back the contemporary emphasis on populations as statistical rather than substantive entities to Adolphe Quetelet's powerful astronomical metaphor, conceived in the 1830s, of l'homme moyen (the average man), and argue for an alternative definition of populations as relational beings. As informed by the ecosocial theory of disease distribution, I then analyze several case examples to explore the utility of critical population-informed thinking for research, knowledge, and policy involving population health and health inequities.

FINDINGS

Four propositions emerge: (1) the meaningfulness of means depends on how meaningfully the populations are defined in relation to the inherent intrinsic and extrinsic dynamic generative relationships by which they are constituted; (2) structured chance drives population distributions of health and entails conceptualizing health and disease, including biomarkers, as embodied phenotype and health inequities as historically contingent; (3) persons included in population health research are study participants, and the casual equation of this term with "study population" should be avoided; and (4) the conventional cleavage of "internal validity" and "generalizability" is misleading, since a meaningful choice of study participants must be in relation to the range of exposures experienced (or not) in the real-world societies, that is, meaningful populations, of which they are a part.

CONCLUSIONS

To improve conceptual clarity, causal inference, and action to promote health equity, population sciences need to expand and deepen their theorizing about who and what makes populations and their means.